Premedication for children at Greenlane Surgical Unit (Daystay)

Background

Perioperative anxiety is common in children and can be a significant challenge for patients, families and the anaesthetic team. Distress associated with this can have lasting psychological implications and can be associated with emergence delirium. For patients with anxiety, limited compliance, special needs, or those requiring repeated procedures, distress can be prohibitive without a combination of effective periprocedural communication and anxiolytic medication.

The goal of premedication is anxiolysis and to facilitate induction of anaesthesia

Indications for premedication

• Age

  • Toddlers to younger school age children can display poor compliance with limited understanding and/or separation anxiety

  • Teenagers may experience anxiety without overt expression

• Limited communicability

  • Children with behavioural or sensory processing disorders, developmental delay or impaired communication may become distressed with procedures, deviation from routine and strangers.

• Patient or parental anxiety or both

• Previous anaesthesia or hospitalisation

  • Prior negative experiences can escalate anxiety

  • Discussing previous experiences, successes, failures and reviewing records will be invaluable guidance for current management.

Facilities, equipment and staff

Appropriate infrastructure must be in place for all children receiving premedication. This includes:

1. Advice and prescription by an anaesthetist

2. Verbal consent from the child’s caregiver outlining expectations:

   1. details of administration and expected effects of premedication

   2. the role of the caregiver in minding the child (see after administration)

   3. the possibility of the premedication being insufficient or paradoxical, and options thereafter.

   4. potentially prolonged sedation post anaesthesia

3. A dedicated and experienced nurse must administer the medication and be available once it has been given, however, they may leave the immediate bed space (See after administration)

4. Access to staff skilled in advanced paediatric life support

5. Access to a dedicated room and transport set up featuring:

   1. A mobile bed for each patient receiving premedication, equipped with:
      i. Pulse oximetry
      ii. A portable oxygen cylinder with an oxygen delivery device (nasal prongs or Hudson mask)

   2. Adequate lighting

   3. Adequate room to perform resuscitation if necessary

   4. Ambu-bag or T-piece with appropriately sized mask

   5. Suction device and yankaeurs/catheters

   6. Access to resuscitation trolley including paediatric airway equipment

   7. Ideally, this environment should be child-friendly with toys, distraction and room for family.

Where to administer

1. Non-ophthalmology patients
   Most premedication charted at GSU will be administered by PACU nursing staff, either in the PACU bays 4 -7 (tonsil room) or PACU bay 1/side room.

2. Ophthalmology patients in Totara ward:

   1. Currently midazolam can be administered and patients monitored in Totara ward

   2. If alternative agents are desired for patients in Totara, these can be administered and the patient then transferred to to be monitored to one of the following:
      PACU bays 4-7 (tonsil room)
      PACU 1/side room
      The preanaesthesia/eye-block bay outside OT5/6 for oversight by the procedural anaesthetic team.

When to administer

• Premedication should only be administered when there is certainty that the operation will proceed, fasting is confirmed and consent has been obtained.

• Each drug should be prescribed on the ‘once-only’ section of the medication chart, with clear instructions for timing, route and dosage.

• Timing of administration is crucial to achieve desired effect and varies by medication. Verbal handover of the prescription to the responsible nurse must be made to ensure it is given on time.

How to administer

• Discuss the process of administration with the child and caregiver, they will know what is most likely to lead to successful administration

• Medications may be administered in a syringe or mixed with a small (<50 mL) volume of juice or water in a cup to improve taste and increase comfort with the process

• Establish a partnership with the caregiver for administration and monitoring the child once the premedication has been given

After administration

• Onset will be gradual. For most medicines, onset of action will be at least 15 minutes.

• It is important to allow the child to move freely as the medication takes effect engaging in usual play initially.

• As the patient starts to show signs of drowsiness, they should be placed on a bed for safety or held by their caregiver

• Children must be transported on a bed to theatre following administration of a premedication.

Information for parents

• The caregiver has an essential role in minding the child. They must be informed of expected effects and know how to call for help.

• Ensure the caregiver is aware that the child could lose balance and strength, become drowsy, fall asleep and rarely their breathing may need to be assisted with oxygen.

• It is important for the caregiver to ensure the child does not fall or sustain injuries.

Choice of premedication

The choice of drug depends on multiple factors, including:

Compliance of the child to take oral medicines

• The oral route is most common

• If a child has spat out an oral premedication, discuss with the anaesthetist whether to attempt again

• Intranasal and intramuscular routes are available if oral cannot be achieved, and must be performed by an anaesthetist

Specific features of each drug:

Please check previous experiences, including allergies and adverse reactions to medicines with the child’s caregiver and the anaesthesia records including medication charts.

Combinations may be required, but beware the synergistic effects of sedation and adjust doses accordingly.

Dosing and administration

• Only ORAL midazolam, clonidine (IV formulation given orally) and ketamine will be administered by nurses at GSU

• We encourage minimising the use of higher doses or multiple agents to avoid prolonged recovery time in the day stay environment.

• If alternative agents or routes of administration are desired, they must be administered by the procedural anaesthetist, who should be readily available as it takes effect.

Suggested premedication dosing for Greenlane Surgical Unit (GSU)

Examples of combination pre-medication strategies and suggested dosing

• Midazolam 0.3 mg/kg PO + clonidine 2-3 micrograms/kg PO

• Midazolam 0.3 mg/kg PO + ketamine 3 mg/kg PO

Troubleshooting

It is helpful to keep a dialogue with the procedural anaesthetist, especially if premedication is spat out, there is a paradoxical reaction, or premedication is insufficient or more profound than expected.

In rare instances the caregiver may not be a suitable candidate to monitor a premedicated child.

• For example, there may be language or other difficulties which can impair the ability to call for help or understand the effects of sedation.

• Between anaesthesia and nursing staff, such caregivers will be supported with appropriate safe monitoring of their child.